Days before her father died in a Montreal hospital, Dolia Todorov called the morgue.

Her father was starving to death while being cared for in a hospital, she said, the last in a series of horrible mistakes.

She was seeking an independent investigation of her father's impending death. After hearing her story, the morgue, in an unusual move, referred her to the Quebec coroner's office.

For the second time that day, Dolia Todorov reeled off a list of gaps in care that converged to seal her father's fate, starting when he was deemed too old for a simple diagnostic test, a colonoscopy, that would have cost the government about $450 and would have detected his cancer.

Instead, he spent nearly three months in a hospital, costing the government about $7,000 a day.

In the end, Ivan Todorov paid the ultimate price. He died on Feb. 1, 2010.

Moved by Todorov's account, the coroner's office, which is called in to investigate accidental deaths, made an exception and agreed to take the case even before Todorov died.

Coroner Jean Brochu told The Gazette that although he will not rule on the cause of Todorov's death, he has serious concerns about his care. His recommendations, to be made public in the coming weeks, will be directed at the Quebec College of Physicians.

What Dolia Todorov wants is to find out how so much could go wrong before his death: mixed-up patient files, a chemotherapy overdose, an untreated E-coli infection, and so many weeks of needless suffering.

"My parents trusted the system

-that was their biggest mistake," Dolia Todorov said at her home in Dollard des Ormeaux, seated in the living room by a picture of her parents on their 60th wedding anniversary. An only child of doctors -her mother was a gynecologist, her father an endocrinologist -Dolia Todorov also studied medicine before switching to computer science.

Three months before he died, Ivan Todorov was a robust 83-year-old, an avid gardener who looked far younger than his years. He didn't smoke or drink and was fastidious about his health.

Todorov's odyssey through the medical system began five years before his death, when he asked for a colonoscopy. Although he had been suffering intermittent stomach pain, his request for the routine diagnostic test was refused. According to his doctor, Radu Popovici, he was too old to worry about colon cancer. When blood tests and kidney X-rays turned up nothing, Popovici told Todorov to visit the ER if his pain worsened.

Almost two years later, on Dec. 23, 2007, Todorov showed up at the Lakeshore General Hospital emergency room doubled over in pain. A scan confirmed colon cancer; a four-hour emergency operation removed the tumour and he went home a week later, supposedly cancer-free -and that meant no chemotherapy.

The results of a routine CT scan ordered in September as part of a followup nine months after the operation by Lakeshore surgeon Gilles Bourdon were lost and it took months -until January -for the family to learn that Todorov's cancer had in fact spread to his liver, two tiny nodes in one area measuring 1.5 centimetres.

"Now what?" Dolia asked Bourdon.

Bourdon replied that he would consult with a Lakeshore oncologist and get back to Dolia the following day.

He didn't.

During this time, her father had a second scan showing that the lesions had nearly tripled in size to four centimetres.

But Bourdon, who was responsible for Todorov's followup care, had missed something else or had failed to report it.

Results of Todorov's blood tests showed alarming levels of carcinoembryonic antigen (CEA), a typical tumour marker used to flag cancer. The family learned of these results only after Todorov's death, when they got copies of his medical files.

Dolia recalled fidgeting at her desk and getting angrier with each passing day. When Bourdon still failed to call her with a treatment plan for her father after five days, Dolia called her lawyer. Armed with a legal letter, she marched into the Lakeshore's administration office with her parents by her side and filed a complaint about medical negligence. She demanded immediate treatment for her father and threatened to sue.

The hospital suggested palliative chemotherapy, but Dolia had learned that Sloan Kettering in New York City offered liver surgery, considered the treatment of choice for patients like her father, and that the procedure had an excellent survival rate. She told the doctors she would be taking her father to New York.

"Suddenly everything became very speedy," Dolia said. Now, the Lakeshore said that Sloan Kettering's operation could be performed in Montreal by liver surgeon Peter Metrakos at the McGill University Health Centre's Royal Victoria Hospital.

The Lakeshore arranged for Todorov's appointment within a week.

There was a final hurdle before surgery, Todorov needed a scan to rule out the possibility the cancer had spread elsewhere in his body. To avoid a three-month wait for the positron emission tomography scan, the family paid $2,500 to have the test done in a private clinic.

Unfortunately, the scan detected cancer cells at the old surgery site. That meant that Todorov needed chemotherapy before his liver surgery.

The treatment worked beautifully -or so Dolia thought. Blood tests showed her father's CEA cancer markers had receded to near normal levels, the liver lesions had shrunk and the cancer cells had disappeared. Todorov was ready for surgery. He was considered a perfect candidate because he was otherwise in excellent health.

The four-hour operation on Nov. 10 was supposed be a "piece of cake," Dolia recalled.

It wasn't.

Chemotherapy is toxic to the liver. Instead of getting the usual four to six cycles of pre-surgery chemo suggested for his type of operation, Todorov was given nine cycles -an overdose. His severely damaged liver fell apart under the surgeon's knife.

After a six-hour wait, Dolia was summoned to a meeting with Metrakos outside the operating room. There was a complication, he explained.

"Metrakos told me that my father had what is known as 'chemo' liver and that it bled profusely and they couldn't close the wound."

At 6 p.m., 12 hours after she had last seen her father, Dolia was allowed a brief visit. Tubes stuck out from everywhere but he was conscious, hungry and eager to go home, she recalled. Dolia called her mother, Maria Gelev, who was waiting at home for an update.

At 2 a.m., Dolia's cellphone rang. It was a resident on Metrakos's surgical team. He said her father had been rushed back into the operating room to close a bleeding vein. It had been damaged during the operation.

Dolia found her father in intensive care the next day. Water filled his lungs. He couldn't breathe and needed a ventilator. He was heavily sedated -in a drug-induced coma. He had a tracheotomy to facilitate his breathing and a feeding tube snaked through his nose.

An ICU physician puzzled over notes in her father's chart referring to the urine bag. According to the chart, her father was fine. But it wasn't his chart.

"My dad was all swollen, and the urine was very dark," indicating that the liver wasn't functioning normally. "They had the wrong ... results attached to his file ... it was data from another patient."

Todorov's condition worsened. His liver function deteriorated. There was nothing doctors could do but "wait and see," Dolia Todorov said. She begged his medical team to reduce his morphine so he would wake up from the coma, induced after the emergency operation performed in the middle of the night to control the bleeding.

Five weeks after surgery, doctors took Todorov off the sedatives at his daughter's request. He awoke 24 hours later and was transferred out of ICU the next day to a room on the ninth floor. He could breathe on his own and spent time watching hockey on television and his granddaughter read him newspapers nightly.

"He still had the feeding tube and he couldn't speak because of the tracheotomy," Dolia said, but now her daily update reports to her mother communicated hope.

On Dec. 20 at 7 p.m., after his daughter had left for the night, Todorov vomited and choked. Liquid filled his lungs. The hospital had to call a "code blue" or an emergency resuscitation.

His feeding was suspended for 48 hours. "He was supposed to be readmitted to ICU but his bed had been given to someone else," Todorov said.

Things took a turn for the worse after nurses tried to restart his feeding. The tube had clogged. It had been left in place without irrigation for two days. Todorov would need a new feeding tube. But after spending a month in ICU on powerful narcotics, Todorov had become hypersensitive to touch. He cried out in pain and could not hold still. A medical student tried to reinsert the tube through his nose while Todorov stayed out in the hall and listened to her father scream. "After several tries, she came to tell me that she couldn't do it, my father was suffering too much." Doctors who had refused to take him off morphine for a month wouldn't give him a tranquillizer to facilitate the insertion of the feeding tube.

Just before Christmas, Dolia learned that her father would not be getting a new feeding tube because he risked vomiting again. Instead, Metrakos assured the family that Todorov would be fed intravenously.

Todorov was now able to speak and was asking constantly for something to eat.

He wanted to go home.

"I would give him sponges with water in his mouth to moisten his tongue," Dolia said. Christmas went by and Todorov was still not being fed, despite daily pleas from his daughter for the promised IV line. He became disoriented.

Todorov's efforts to help her father went nowhere: "He was starving to death -right in the middle of the freakin' Royal Victoria Hospital."

The family also wanted to take Todorov home. "We'd hire a nurse to take care of him 24/7. But they said it couldn't be done."

On Dec 28, after a week without food, Todorov finally got fluid nutrition through an IV line. But he was hallucinating and his flailing arms ripped the line out. Doctors never inserted a new one.

A helpless Todorov watched her father beg for food. His trembling hands reached for imaginary bread. He whispered for bread and milk.

"He was pleading with me, 'Please Dolie, give me some milk.' My heart was breaking to see him like this," she said. "But no one wanted to listen to me."

Dolia located the residents in the hospital cafeteria the day after New Year's. "If you do nothing, my father will never get out of this hospital alive," Dolia told them. Everything is under control, they replied.

The next morning, Todorov's condition worsened rapidly -his kidneys stopped functioning, he was dehydrated and running a fever. A nurse called a surgical resident for an evaluation. No resident came. By 3 p.m., a distraught Dolia took the stairs herself -twice -to try to get someone from the ICU to help her father on the ninth floor. But the doctor on call was not available. At 5 p.m., Dolia tried again and this time ran into a doctor whose name she recalls as "Dr. Amin" who knew her father when he was in the ICU. He was with a patient but promised to come to her father's room.

"He tells me my father is 'crashing,' " Dolia recalled, which meant that several organs were shutting down, his blood pressure was falling, he had difficulty breathing, and there was a mystery infection. Todorov was admitted into the ICU at midnight. He got large doses of antibiotics. Finally, on Jan. 4, he got an IV line, which later that day was judged to be the wrong approach. The next day, doctors inserted a feeding tube directly to the stomach. His medical report that day noted "patient has been having poor nutrition for past two weeks."

It was too little, too late. By then, Todorov had been starving for 15 days and his weakened body rejected the nutrients like a foreign substance. At least one doctor lobbied for palliative care: Let your father go, it's a losing battle, he told her.

"You can't find a doctor at the Royal Victoria to look after your father, but here's one that spent 45 minutes trying to convince me to let him die."

Dolia spent days by her father's side. She asked ICU doctors about the holes in his care. "They encouraged me to do something about it so that this doesn't happen again to other patients," she said.

The day he died, the family gathered to say goodbye, and then left Dolia to stay to the end. One of the nurses comforted Dolia, telling her he would be happy that she was by his side. "I sat down and started crying."

By the time he was taken off the respirator, none of her father's organs functioned normally.

Then Dolia learned that her father had acquired a hospital-borne infection, Ecoli, for which he did not get treated. She flew into a rage. "Why wasn't that mentioned when they lobbied to discontinue care? Suddenly, no one wanted to speak to me anymore." A nurse threatened to call security.

Todorov continues to see a

psychotherapist once a week to help her deal with her father's death. She is considering taking legal action against the hospitals and doctors involved. "This has marked me for the rest of my life," she said.

Every night before sleep, she sees her father's image begging for a drop of milk.

"If it wasn't for one mistake after another, my father would be in his garden today."

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